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Waste Tire Survey & Inspection Report inspection Report Number ■ <br /> State of Calif—la <br /> Survey Form Page 1 1 3 - 1 0 1 3 4 7 3 <br /> CIWMB 181(New 04104) <br /> Caliromia Integrated WastesteManagement Board <br /> Part A-Survey _ BLUE_OR BLACK INK PEN <br /> Business Profile _ Inspection Details <br /> TIMID- / O 1 - O 1 Inspection Type (Fill one) <br /> ffi — <br /> Site Suffix: / J _ 0 Routine Q Re-inspection Q Referral Q Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: S� �Q�;, Q CHP CIWMB Complaint Q Educational Visit Other <br /> Business or Facility Name <br /> Inspected BY Inspector <br /> Physical Address Grp 3 7 <br /> �D O� /"r Qlu-Gcct� <br /> Inspection Date ,O 57 <br /> Time In Time Out <br /> Business Rep Title / O : 3 3 O PM / tJ 7 O AM <br /> O PM <br /> Operational Status Tire Type Business Role Storage Type <br /> Tire Count(Whole/PTE) / / (Fill one only) (Fill all that appy) (Fill all that apply) (Fill all that apply) <br /> b o 0 Active 0 Passenger 0 Generator Q Outdoor <br /> OO Closed Q Altered <br /> GPS Latitude 0 Hauler 0 indoor <br /> O 0Inactive 0 Truck <br /> Longitude - Q Planned 0 OTR 0 End-Use 0 Container <br /> J <br /> Business Type (Fill all that apply) <br /> 0 New Tire Dealer 0 Auto Repair Trucking Fleet Q Government o Re—treader Dismantler Tire Derived Fuel <br /> 0 Used Tire Dealer O Auto Body 0 Car Dealer 0 Collection O Crumb Rubber <br /> O Service Station O Hauler O Agriculture Q Shredder 0 Other <br /> Part B-Inspection of Waste Tire Dealer,Generator,Hauler and End-Use Facility <br /> O O PRC§42951-Waste Tire Hauler Registration and Transport of Tires <br /> O O PRC§42953-Contracts With Registered Waste Tire Haulers. <br /> Q O PRC§42956-Registration/Decal in Vehicle <br /> O O 14 CCR§18459 -Responsible Entities Complying with Manifesting Requirements <br /> Q O 14 CCR§18459.1(a)(b)(c)-Tire Program ID Number from CIWMB <br /> O O 14 CCR§18459.2.1-Submittal of Manifest Forms and Tire Trip Logs within 90 days <br /> O O 14 CCR§18459.3-Retention of Manifest Forms and Tire Trip Logs for 3 years <br /> 0 0 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers �. <br /> O O 14 CCR§18461-Manifest System Requirements for Waste Tire End-Use Facilities <br /> O O 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators <br /> O O Other: § •�,�e� J <br /> Comments17 <br /> �Qea�i�2 SKS, bn 11FT.t%S Gx 4w�C W4d <br /> h j-* <br /> Inspection Form Included: <br /> Comments Included:Q 3 0-67 Do '0 " `r68 0' <br /> Busi ess`Rep's Signature Phone Number inspector's Signature Phone Number TI� <br /> INSTRUCTIONS ON BACK Ire IXIAIMIPILIEI 11213 62081 <br /> ■ White Copy.CIWMB Yellow Copy:Operator Pink Copy:LEA ® ■ <br /> 0615104.0427 <br />